Characteristics associated with anti-HCV serological markers in prisoners in the state of Paraná, Brazil: a case-control study

w w w . e l s e v i e r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Original

article

Characteristics

associated

with

anti-HCV

serological

markers

in

prisoners

in

the

state

of

Paraná,

Brazil:

a

case-control

study

Tânia

Maria

Pazin

Marques

Silva

_,

_Lirane

_Elize

_Defante

_Ferreto

_,

Franciele

Ani

Caovilla

Follador

_,

_Ana

_Paula

_Vieira

_,

_Roberto

_Shigueyasu

_Yamada

_,

Léia

Carolina

Lucio

_,

_Joana

_Perotta

_Titon

_,

_Renata

_Himovski

_Torres

_,

Greicy

Cézar

do

Amaral

_,

_Harnoldo

_Colares

_Coelho

a_{WesternParanáStateUniversity,DepartmentofLifeSciences,PostgraduatePrograminAppliedHealthSciences,FranciscoBeltrão,PR,}

Brazil

b_{WesternParanáStateUniversity,DepartmentofLifeSciences,GeneralSurgeryResidencyProgram,FranciscoBeltrão,PR,Brazil.}

c_{DivisionofPublicSecurityandPenitentiaryAdministration,PenitentiaryDeparment,Curitiba,PR,Brazil.}

d_{15thHealthDivision,StateHealthOffice,Maringá,PR,Brazil}

e_{SãoPauloStateUniversity,DepartmentofPharmacy,RibeirãoPreto,SP,Brazil}

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o

Articlehistory:

Received7February2019 Accepted21May2019 Availableonline20June2019

Keywords:

HepatitisC Riskfactors Prisoners

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Background:TheprisonsysteminParaná,Brazil,isexperiencingseriousproblemsrelated

totheincreasingnumberofprisoners.ControlofhepatitisCvirus(HCV)hasbecomemore intensebecausetheincarceratedpopulationisconsideredahigh-riskgroupforcontagious diseasesduetothefavorableconditionsfoundinprisonsforthespreadofthesemorbidities. TheobjectiveofthisstudywastoidentifyfeaturesassociatedwithhepatitisCinfection amongmaleprisonersincorrectionalinstitutionsofParanástate,Brazil.

Methods:Thiswasacase-controlstudy(27casesand54controls)ofmenincarceratedin

11penitentiariesinParaná,Brazil.Informationwasobtainedthroughaquestionnaireina cross-sectionalepidemiologicalsurveyonHCVinfectionduringtheperiodfromMay2015to December2016.Eligiblemenwererecruitedaftertestingpositiveforanti-HCVantibodies. Casesandcontrolswereselectedbasedonserologicalresultsofenzyme-linked immunosor-bentassaysandwerematchedbyage,location ofthepenitentiary,andtimeinprison. LogisticregressionanalysiswasusedtoidentifyriskfactorsforHCVseropositivity.

Results:ThemainsignificantindependentriskfactorfortheacquisitionofHCVinfection

wastheuseofinjectabledrugs(OR=4.00;95%CI:1.41–11.35;p<0.001).

∗ _{Correspondingauthor.}

E-mailaddress:liraneferreto@uol.com.br(L.E.Ferreto).

https://doi.org/10.1016/j.bjid.2019.05.007

1413-8670/©2019SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

174

Conclusions: ThisstudyprovidesevidencethatHCVinfectionisassociatedwithdruguseby

thispopulation.Thisinformationispivotalfortailoringpreventionprogramsandguiding specificsocioeducationalmeasuresthataimtoreduceorpreventHCVtransmissionwithin theprisonsetting.

©2019SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.Thisis anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Introduction

InfectionwithtypeCviralhepatitis(HCV)iscommonamong the prisonpopulation. Itis alsothoughtthat incarceration itselfmayincreasetheriskofinfection.1,2_{Thisincreasedrisk}

can be attributed to several causes, some associated with theprisons’structuralandlogisticproblemsandotherswith commonproblemsorbehaviorsacquiredduringseclusion.2,3

Worldwide,itisestimatedthatapproximately 15.1%ofthe 10.2millionincarceratedindividualsarelivingwithHCV.4_This

rateislowerthantheprevalencereportedamongprisoners ininternational studies,including studies inItaly (22.4%),5

Indonesia(34.1%)6_{andAzerbaijan(38.2%).}7

Awide variationinanti-HCVprevalenceinthe incarcer-atedpopulationhasbeenreported,rangingfrom1%inastudy carriedout in Colatina,Brazil,8 _{to47.4% inastudy carried}

outinAustralia.9_{InasystematicreviewbyMagrietal.,}

hep-atitisC prevalenceranged from 1%to41% in Brazil.1 _This

variationisassociatedwithdifferencesingeographicalprison location,age,previousprisonsentences,intravenousdruguse, andeventhequalityofpublichealthservicesavailabletothe population,aswellaswiththedifferenthabitsandhigh-risk behaviorsindifferentgeographicalregions.10–13

Contamination by HCV in prisons has been linked to trauma-inducedbloodexposure,tattooing,intravenousdrug use,andsexualactivity.1,2,9,14–19_{Confinementplusadditional}

factors(sharingofmaterialusedfordruguse,tattoos, pierc-ings,andrazorbladesinadditiontoinadequatesterilization orreuseofmedicalordentalinstruments)and deficiencies inhealthcarealsoincreasethevulnerabilityofprisonersto HIV/AIDSandothersexuallytransmittedinfections.1,15,20–23

Althoughthere is someunderstanding of the scenarios thatleadtothetransmissionofinfectiousdiseasesinprisons, epidemiologicalstudies are stillscarce forthis population, especiallyinBrazil.Recently,asystematicreviewofstudies from1989to2014conductedbyMagrietal.ontheprevalence ofhepatitisCinprisonersinBrazilconfirmedthatnoneofthe reviewedstudieshadbeenconductedinthestateofParaná, Brazil.1 _{This studyaimed toanalyzethe factors associated}

withhepatitisCinfectionamonginmatesoftheParanáprison system.

Materials

and

methods

Thisstudywasprecededbyacross-sectionalsurveycarried outfromMay2015toDecember2016in11penitentiariesin Paranástateentitled“PrevalenceofHIVandHepatitisBandC intheprisonpopulationinthestateofParaná.”Basedon

infor-mationfromthePenitentiaryDepartmentofParaná(DEPEN, PR)atthetimeofthestudy,therewereapproximately19,000 prisoners in23closedmale prisons.Elevenofthe23 high-security closed prisons insix cities ofthe state (Francisco Beltrão,Londrina,Curitiba,SãoJosédosPinhais,Pinhais,and Piraquara)wereincluded(Fig.1).Ourcriteriaforselectingthe participating citiesconsideredboththesizeofthecitiesas wellasthepresenceofpenitentiariesinclosedregime.Three cities–alllocatedinthestateofParaná–werethenselected totakepartinthisstudy(FranciscoBeltrão,asmall-sizedcity, withapopulationofupto100thousandinhabitants;Londrina, arelativelylargecity,butwithlessthanonemillion inhabi-tants;andCuritiba,thecapitalcitywithmorethanonemillion inhabitants).24_{Intheclosed-regimesystems,inmatesremain}

underdailysupervisionwithintheprisonlimits.

The sample sizewas calculated based on the expected prevalenceof50%HCVinfectionwith1%variation,apowerof 80%,and3%alphaerror.Thestudypopulationincluded8,142 inmates,andthestudysamplesizewas954inmates. Approxi-mately25%moreindividuals(total:1192inmates)wereadded toaccountforanticipated lossdue toparticipationrefusal. Proportional stratified sampling was performed using each prisonasarandomizationunit.Atotalof1132prisonerswere interviewed,with60lossesorrefusals(5%).Onthedayofdata collection,theprisonersweresortednumericallyin ascend-ingorderfromthelistsprovidedbytheprison,andalistof randomnumberswasgeneratedusingthesoftwareMicrosoft

Excel®2007.Tobeincluded,patientshadtobe(a)aged18years

orolder;(b)incustody,(c)abletoconsentforthemselves,(d) abletobeinterviewedonlybyaresearcher(withoutrisk mark-ers),and(e)abletounderstandspokenPortuguese.Thisstudy wascarriedoutwiththeapprovaloftheresearchEthics Com-mitteeoftheStateUniversityofWestParanáunderapproval number810.574.

Alleligibleparticipantsprovidedvoluntaryinformed writ-ten consent prior to participation in the study and no compensation was provided. The treatment offered to the individualswhodidnottakepartinthestudywasthesameas thatgiventoparticipants.PrisonersidentifiedasHCV-positive receivedmedicalassistance.Toinvestigatetheprevalenceof anti-HCV antibodies,weuseda 3rdgeneration chemilumi-nescentenzymetest(Architect®anti-HCVassay—Germany) inserumsamplesonai4000instrument(ArchitectSystem, UnitedStatesofAmerica[USA]).Testresultswereanalyzed accordingtothemanufacturer’sinstructions.

Basedontheresultsoftheabovecross-sectionalsurvey,we planned thiscase-controlstudyduringtheperiodofMarch through May2018toinvestigatethe riskfactorsassociated anti-HCVseropositivityamongmenincarceratedintheclosed

Fig.1–GeographiclocationsofthepenitentiariesincludedinthestudyinParaná,Brazil.

PEL,StatePenitentiaryofLondrina;CRESLON,SocialReintegrationCenterofLondrina;PEP,StatePenitentiaryofPiraquara; PCE,CentralStatePenitentiary;CCJP,HouseofCustodyofSãoJosédosPinhais;CCC,HouseofCustodyofCuritiba;CCP, HouseofCustodyofPiraquara;CMP,CriminalMedicalComplex;PFB,StatePenitentiaryofFranciscoBeltrão;RM, MetropolitanRegionofCuritiba.

19.000 prisoners in 23 prisons in the state of

Paraná - Brazil

Study populationin 11 prisons in the state of Paraná - Brazil – 8.142

Anti-HCV (+ 30 prisoners Anti-HCV (-) 1.102 prisoners)

3 excluded cases 2 controls for each case (pairing)

Cases Anti-HCV (+) 27 prisoners Controls Anti-HCV (-) 54 prisoners

Case and controls 81 prisoners

176

regimeofthe penitentiary systemof Paraná,Brazil. Inthe firststudy,30prisonersanti-HCVreactivewereidentified.Out ofthese,27casesfrom eightpenitentiariesofParanáwere matchedforsamepenitentiary,timeofimprisonmentwithin fiveyears,andagewithinthreeyearswith54controlsubjects. Threecaseswereexcludedbecauseitwasnotpossibletofind matchedcontrolsforthem.Acasewasdefinedasanyinmate withreactiveserologyforHCV.Controlswereselectedfrom amongprisonerswithserologicmarkersfornon-reactiveHCV. AflowchartoftherecruitmentstrategyisshowninFig.2.

After cases and controls selection, the following infor-mation was obtained: race/color, marital status, schooling, occupation when incarcerated, number oftimes in prison, convictiontime,STDhistory,knowledgeabouthepatitisBand Ctransmissionroutes,bloodtransfusionhistory,tattooand piercinghistory,illicitdruguse,injectabledruguse,condom use,alcoholicbeverageuse,sexualorientation,homosexual relationshiphistory, and intimatevisithistory. Anonymous identificationnumberswereusedtocross-referencethe infor-mationcontainedinthequestionnaires.

All processing and analysis steps were performed with theStatisticalPackageforSocialScience,version24.0(SPSS Inc., Chicago, IL, USA) program. Absolute (n) and relative (%) frequencies are used to describe the sample features. Initialcomparisonsbetweengroupswereperformedby facto-rialANOVA(groupsvspenitentiaries).Comparisonsbetween casesand controlsforcategoricalvariableswereperformed usingchi-square testswith continuitycorrection.Variables thatpresentedp<0.20inunivariateanalysiswereincluded intoabinarylogisticregressionmodeltoidentifyindependent riskfactorsforHCVinfection(p<0.05).

Results

HCVseroprevalence identified inthe survey“Prevalence of HIVand HepatitisBand C inthe prison populationofthe ParanáStatePenitentiaries”was2.7%(95%CI1.9–3.8).Cases (n=27)andcontrols(n=54),selectedconcomitantly,werenot significantlydifferentintermsofpenitentiary,age,andtime ofimprisonment(Table1).

Table2showsthegeneralcharacteristicsofthetwogroups. Themeanagewas39years,andpositiveserologywas pre-dominantly foundamongindividuals over 30 years ofage. Although the differences were not statistically significant, the cases had a higher prevalenceof unemployment, had beeninprisonmoreoften,reportedgreaterknowledgeabout hepatitis,and hadhigher prevalenceofblood transfusions, illicitdruguse,andhomosexualrelationshipsthanthe con-trols. However, the only variable independently associated with anti-HCV seropositiveness after multivariate analysis wasinjectabledruguse(OR:4.095%CI1.41–11.35).

Fourvariableswithap<0.20(Table2)wereincludedinthe logisticregressionmodeltoidentifyindependentriskfactors foranti-HCVreagent (Table3).Ofthese, twovariables per-sistedsignificantlyassociated:illicitdruguseandinjectable druguse.Asthetwopresentedhighcollinearity(thosewho usedillicitdrugswerethesameindividualswhoused inject-ingdrugs),constructionofamultipleregressionmodelwas notpossible.However,giventhenarrowconfidenceinterval

oftheORintheinitialanalysis,injectingdruguseisthemain riskfactorforhepatitisCinfectioninprisoners.

There have been few studies in Brazilian male prisons assessingriskfactorsforhepatitisCinfection.1_Mostofthese

studieshaveaimedjusttodeterminetheprevalenceofHCV seromarkers.12 _{Therefore, among the contributions of this}

study,wehighlightthecase-controldesignwith representa-tion ofprisonersin11closed-regimemalepenitentiariesin thestateofParaná.Itisworthmentioningthatthisisthefirst studyinthestatethatshowsaclearviewoftheprevalenceof HCVandtheriskfactorsrelatedtoexposureamongprisoners. The prison population is considered to be at high risk for acquiring infectious diseases1,25 _{because prisoners are}

confined and present risky behavioral factors such as low educationallevel,25_{irregularandinfrequentuseofcondoms,}

multiplesexualpartners,sexundertheinfluenceofalcohol and drugs,26–28 _{and irregular use ofpreventive measures.}1

Theseriskfactorsandbehaviorscanprecedearrestand fre-quentlycontinueduringincarceration.18,29

Prisoners witha historyofprevious incarcerationshave hadagreateropportunitytoacquireHCVinfectionthanthose whohavenotbeenpreviouslyincarcerated.1,18_Several

stud-ies have revealed that previous history of incarceration is related tofrequentexposuretohigh-risk activitiessuchas unsafelifestyles,riskysexualbehaviors,exposuretosharps fortattooing,andsharingofneedles,syringesandother para-phernaliaforillicitdruguse.1,12,18,25

Recently,Stoneet al.publishedasystematicreviewand meta-analysisof41studiesonthissubject.Ithasbeen iden-tifiedthatbothrecentandpastincarcerationcontributetoan increasedriskofHCVacquisitionrangingfrom21%to62%.30

Inthepresentstudy,previousincarcerationwassignificantly associatedwithHCV infection inunivariateanalysis. How-ever,thisfactorwasnotconsideredanindependentpredictor ofviralinfection,suggestingthattheremustbeotherfactors thatconfoundtherelationshipbetweenthesetwovariables.29

Studieshaveidentifiedthathomosexualrelationshipoffer agreaterchanceofHCVinfectionthanheterosexual relation-ship;in ourstudy,inthe final model,this association was notconfirmed.28–32_{Itisbelievedthatthisassociationmaybe}

relatedtoriskbehaviorsratherthantohomosexualityitself, accordingtoReekieetal.33

Inthisstudy,illicitdrugusewasassociatedwithHCV expo-sure.Thesefindingshavealsobeenidentifiedinotherstudies worldwideandinBrazil.18,25,29,32 _{Despitethesignificanceof}

illicitdruguseinunivariateanalysis,inthefinalmodelonly injectingdrugusewasassociatedwithpositiveserologyfor HCV,sincethosewhousedillicitdrugswerethesame individ-ualswhousedinjectingdrugs(collinearity).Inourstudy,the oddsofcontractinghepatitisCwerefour-foldhigherformen who usedinjectingdrugs(OR=4.00;95%CI:1.41–11.35)than forprisonersinthesame prisonsystemwhodidnotinject drugs. Injectingdrug-usingprisoners andmalesina meta-analysisstudywere24timesmorelikelytobeHCV-positive thannon-injectingdrugusers.26

Worldwide,thereisacontinuingepidemicofHCV infec-tion amongyoungwhite adultswho injectdrugs, areaged lessthan 30years,andwithahistoryofpreviousor simul-taneous opiateconsumption.33,34 _{HCV infection prevalence}

Table1–Descriptionofthepairedvariablesofthecases(27)andcontrols(54)accordingtothepenalunit,averageage, andprisontimeinthestateprisonsofParaná.

Penitentiary SampleN Averageage Averageprisontime

Case Control Case Control Case Control

PFB 01 02 32a _{31,00±1.14 9}a _7±0.00 PELI 02 04 45.50±2.12 45.25±2.63 4.50±2.12 5.00±3.74 PELII 04 08 45.25±11.53 44.63±10.24 3.50±2.08 3.75±2.60 PEC 07 14 42.29±8.14 42.21±7.89 4.71±2.69 5.36±3.93 PEPII 05 10 32.60±9.81 33.10±8.60 1.80±1.92 2.00±2.40 CCC 03 06 39.33±3.78 38.17±3.43 1.67±2.08 2.00±1.26 CCP 03 06 30.67±9.02 30.67±8.07 0.33±0.57 0.16±0.40 CMP 02 04 39.50±0.71 44.50±11.03 0.50±0.71 0.75±1.50 Total 27 54 38.96±9.10 39.13±9.26 14.25±14.06 15.11±12.63 EffectsofANOVAinformationforcasevscontrol:age(F=0.017;p=0.896)andprisiontime(F=0.001;p=0.999).

a _{Justonesubject.}

higherratesamongnewinjectors.Aquarterofinjectingdrug userswillbeinfectedwithintwoyearsafterstarting.In addi-tion,HCVisapproximately10timesmoreinfectiousthanHIV, andinjectingdruguseincreasestheriskby3–10%compared to0.3%forHIVcontamination.Furthermore,thevirusremains infectiveinliquidandsyringesandoninanimatesurfacesfor weeks.35–37

Therelationshipbetweenillicitdruguse,HCVinfectionand imprisonmentisveryclose,asinjectingdrugusers(IDUs)are theindividualswiththehighestratesofincarcerationdueto involvementinillicitactivities,andtheygetinvolvedcriminal activitiestofinancetheiraddictions.38_{Arecentmeta-analysis}

ofsixpublishedstudiesontheincidenceofHCVinprisoners reportedthattheriskofHCVinfectionwaseighttimeshigher ininjectingdrug-usingprisonersthanininjectingdrug-using non-prisoners.30

Inacohort of735Australianprisonerswithahistoryof injectingdrugusethatwerefollowedformorethan14years, 55.1%ofprisonerswerefoundtohavesomehistoryofHCV, and47.4%ofthosetestedintheprisonwereseropositivefor HCV.Inthisstudy,druginjectioninprisonwasfoundtobe stronglyassociatedwithHCVseropositivitybySnowet al.9 Rouxetal.alsoreportedinjecting drugusein99%ofcases intheirsurveyofsociodemographicandbehavioral charac-teristicsofparticipantstestedforHCVinfectioninaprison populationinsouthwesternFrance.39

InLatin America and the Caribbean,11.3% ofprisoners coinfectedwithHIVandhepatitisCuseinjectingdrugs,and inBrazil,theprevalenceisapproximately9.2%.40_InBrazilian

studies,therearereportsofsyringesharingfordrugusein 32.5%ofprisoners.Theuseofillicitdrugsiscommoninprison environments,andevenwhentheuseofonlyinhaledillicit drugshasbeenreported,highfrequencyofuseendsupbeing abridgetoinjectabledruguse.41_{Pereiraetal.,intheirstudyon}

populationsfrom26BrazilianstatesandtheFederalDistrict, showedinamultivariatemodelthatuseofinjectabledrugs (OR=6.65;95%CI:2.47–17.91)andofinhaleddrugs(OR=2.59; 95%CI:1.34–5.81)werepredictivefactorsforHCVinfection.41

The epidemiological impact of various risk factors for acquiringHCVinfectionhasbeeninvestigatedinanumber ofstudiesonprisonpopulations,andinjectingdrugshasbeen foundtobethemainriskfactorassociatedwithHCVinfection

inprisonpopulations.9,10,30,37_{Althoughsuchriskbehavioris}

strictlyprohibitedinprisonsaroundthe world,almosthalf of illicit drug users continue to use such substances after arrest.Inaddition,thedifficultyinobtainingsterileinjecting equipmentinprisonresultsinwidespreadsharingofinfected equipmentandincreasedriskofHCVtransmission.12

Itshouldbeclarifiedthattheuseofinjectingdrugsisalsoa riskfactoroutsidetheprisonenvironment.Indeveloped coun-tries,mostnewHCVinfectionsarereportedininjectingdrug users.ThemostrecentsurveysofactiveIDUsintheUnited Statesindicatethatapproximatelyonethirdofyoungusers (ages18–30)areinfectedwithHCV.42

TheseroprevalenceofHCVobservedinthisstudywas2.7%, which is higher than that in the range of 0.7%and 1.38% reportedamongpeopleaged10–69years.41,43,44_Inthisstudy,

HCV seroprevalencewasslightly higherthan thatfoundin astudybyPugaetal.18 _{amongmeninpenitentiariesinthe}

stateofMatoGrossodoSul(2.4%),butlowerfromtherates foundinstudiesonprisonersinthestatesofSãoPaulo(8.7%) andMinasGerais(6.34%).24,45_{TheprevalenceofHCVinfection}

amongprisonersinParanáwasalsolowerthanthatfoundin studiesinAustralia(29%),England(24.2%),Italy(22.4%),Ghana (18.7%),Iran(7.4%),andLebanon(3.4%).46–48

ThepresenceofHCVcanbemanifestedasanacute infec-tion,withdevelopmentofsymptomsin20–30%ofcases,oras achronicinfectionthatcanresultinliverfibrosis,cirrhosis,or hepatocellularcarcinomain70–80%ofcases.33,34_The

possibil-ityofinfectionwithoutapparentsymptomsmakesitdifficult todiagnoseinfectionearlyand,consequently,postpones diag-nosis and treatment of chronic patients. This situation of delayeddiagnosisisfrequentwithintheprisonsystemsince theinfrastructureandhealthservicesinthesystemtocare fortheprisonerarepoor, whenexistent.48 _{Thereisalsoan}

absenceofeducationalcampaignsandguidanceforthe prac-ticeofsafesex,sexualtransmissionamongmenwhohave sexwithothermen(HSH)ishigherintheprisonenvironment than intheoutside environment,reachingratesof8,6%.In relation tothe HIV-positiveprisioners, areport from Israel showedarateof6.5%amongHSHwhohadanalsexbefore imprisonment.49

Educationalcampaignsandguidelinesforthepracticeof safe sexamongthe prison population would beuseful for

178

Table2–Sociodemographiccharacteristics,riskfactors,prisonvariablesandHCVinfectionamongmaleprisonersofthe penitentiariesofthestateofParaná,Brazil(n=81).

Cases(n=27) Control(n=54) p-Value

n % n % Skincolor White 13 48.1 29 53.7 0.814 Other 14 51.9 25 46.3 Maritalstate Married/cohabitating 11 40.7 28 51.9 0.479 Single/divorced 16 59.3 26 48.1 Education

Incompleteelementaryschool 14 51.9 27 50.0 0.875

Completeelementaryeducation 13 48.1 27 50.0

Wereemployed

Yes 9 33.3 26 48.1 0.303

No 18 66.7 28 51.9

Numberoftimesintheprisonsystem

Upto2times 5 18.5 19 35.2 0.197

Morethan2times 22 81.5 35 64.5

Convictiontime

Upto12years 15 55.6 26 48.1 0.694

Morethan12years 12 44.4 28 51.9

DSThistory

Yes 11 40.7 26 48.1 0.693

No 16 59.3 28 51.9

Knowledgeabouthepatitis

Yes 14 51.9 20 37.0 0.301 No 13 48.1 34 63.0 Bloodtransfusion Yes 7 25.9 8 14.8 0.363 No 20 74.1 46 85.2 Tattooing Yes 19 70.4 32 59.3 0.464 No 8 29.6 22 40.7 Piercing Yes 5 18.5 12 22.2 0.923 No 22 81.5 42 77.8

Illicitdrugsuse

Yes 24 88.9 36 66.7 0.060

No 3 11.1 18 33.3

Injectingdruguse

Yes 12 44.4 9 16.7 0.016 No 15 55.6 45 83.3 Condomsuse Yes 14 51.9 32 59.3 0.418 No 4 14.8 9 16.7 Donotknow 9 33.3 13 24.1 Alcoholconsumption Yes 24 88.9 49 90.7 0.794 No 3 11.1 5 9.3 Sexualorientation Heterosexual 25 92.6 47 87.0 0.708 Other 2 7.4 7 13.0 Homosexualrelationship Yes 5 18.5 3 5.6 0.148 No 22 81.5 51 94.4 Intimatevisit Yes 7 25.9 19 35.2 0.556 No 20 74.1 35 64.8

Table3–IndependenthepatitisCpredictorsofanti-HCV seropositivenessinmenarrestedinthepenitentiary systeminParanábymultivariatelogisticregression analysis.

ORbr(IC95%) p

Numberoftimesintheprisonsvstem

Upto2times 1

Morethan2times 2.39(0.78–7.32) 0.128 Illicitdrugsuse

Yes 4.00(1.06–15.08) 0.041

No 1

Injectingdrugusea

Yes 4.00(1.41–11.35) <0.001

No 1

Homosexualrelation

Yes 3.86(0.85–17.60) 0.081

Nn 1

a _{Mainvariableinthefinalmodel.}

reducingtheprevalenceratesofHCVandothersexually trans-missiblediseases.Lackofhealthybehaviorisrelatedtothelow effectivenessofthe medicalteamsinprisonenvironments, whichhindersmedicalcare,sinceprisonsareenvironments characterizedbyconditionsofinsecurityandfear.50

Thisstudyhaslimitationsbecausesomebehavioralrisks may have been underreported by the participants due to the fact that vulnerability can lead to discrimination and stigmatization.Suchunderreportingcouldhavecontributed tounderestimation of the potential risk factors associated withHCVexposure.

Inconclusion,weobservedinjectabledrugusetobethe mainrisk factor for hepatitisC infection inmen incarcer-atedinthepenitentiary systemofParanástate,Brazil.The increasedriskwasassociatedwithahighfrequencyofrisky behaviorbeforeandduringincarceration,especiallyfor inject-ing drug users. These results suggest an urgent need for effectivepreventionprogramming,education,prison strate-gies,andprogramsadaptedtolocalcontextsaswellasnew direct-actingantiviraldrugs,treatmentstrategies,and thera-pies.

Serologicaltestingforscreeningand monitoringofIDUs andtreatmentofdrugabuseandaddictionamongprisonersin needintheprisonsystemwouldmakeitpossibletoevaluate thesuccessofharmreductionstrategies(needle/syringe shar-ingprogramsforinjectingdrugsandtattoos).Finally,studies usingphylogeneticanalysiswillalsoenhanceunderstanding oftheroutesofHCVtransmissioninthispopulation.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgement

ThisresearchwasfundedbytheMinistryofHealth(Brazilian Government)andWesternParanáStateUniversity(UNIOESTE) underagreement797322/2013.

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